Forms
How to View and Download
To view or download a file, select the desired language link. The PDF file will open in a new window or tab of your browser. From there, you can also download or print the file.
Medical Claim Form for Group
- Medical Claim Form – English (PDF)
- Medical Claim Form – En Español (Spanish) (PDF)
- Behavioral Health Claim Form – English (PDF)
Group Member GRIEVANCE FORM
Continuity of Care Assistance Request Form
- Continuity of Care Assistance Request Form – English (PDF)
- Continuity of Care Assistance Request Form – En Español (Spanish) (PDF)
Disabled Dependent Certification Form
Mail Order Pharmacy
- CVS Caremark Mail Order Pharmacy – English (PDF)
- CVS Caremark Mail Order Pharmacy – En Español (Spanish) (PDF)
Prescription Claims
- Prescription Drug Claim Form (Commercial Members) – English (PDF)
- Prescription Drug Claim Form (Commercial Members) – En Español (Spanish) (PDF)
Prescription Transition Form
Glossary of Health Coverage and Medical Terms
- Glossary of Health Coverage and Medical Terms – English (PDF)
- Glossary of Health Coverage and Medical Terms – En Español (Spanish) (PDF)
- Glossary of Health Coverage and Medical Terms – Chinese Mandarin 中文 (PDF)
- Glossary of Health Coverage and Medical Terms – Navajo – Diné bizaad (PDF)
- Glossary of Health Coverage and Medical Terms – Korean 한국어 (PDF)
Health insurance companies and group health plans are required to make available a uniform glossary of health coverage and medical terms commonly used in plan documents. The Uniform Glossary is meant to help the consumer understand some of the most common language used in health insurance documents. Please log in to request a hardcopy of the document by mail.